Case vignette: Nicholas
When I commenced work with Nicholas, he was eight years old and had learning disabilities with associated emotional and behavioural problems. He was very controlling, often saying ‘Shut-up!’ or ‘Be quiet!’ if I started playing the piano. However, Nicholas did allow me to play the flute and this led to him using the melodica. It was clear that he was motivated to choose the melodica because of his desire to blow into an instrument. Nicholas accepted the boundary that he could not play the therapist’s flute and took ownership of the melodica. He has since used it many times in the past three years, gradually experimenting with different scales, chords and intervals. Each time, his music is beautiful, sonorous and moving. Nicholas has a troubled home life but is very loving and keen to learn; unfortunately his keenness is often hindered by his emotional state. He can get very angry but his music, particularly the flute and melodica duets, seem to tap into the gentle side of his character, which he allows to come to the fore in these moments. Nicholas always makes clear endings using a diminuendo, giving the feeling of a sigh.
Case vignette: Anna
Anna is a profoundly disabled girl who I began to work with in music therapy sessions when she was three years old and this work continued for four years. Anna engaged in music and movement therapy work with an adult facilitating her movements. She was blind and could not move unaided but clearly wanted to get close to the source of the music. Frequent early sessions with Anna’s head resting on the therapist’s crossed legs and moving her flute close to the young girl’s face produced delight when she felt the breath and, with adult facilitation, touched the flute as I played. This felt extremely close. My mirroring of the rhythm of Anna’s breathing added greater security to our relationship. The flute being ‘breathy’ seemed to make the perfect link and helped her to realise that she was dictating the improvisations.
In both of the case studies above, the flute was a far more appropriate instrument of choice than the piano. It was not so intimidating for the children and the sound appealed to them. In addition to this, the flute facilitated the children’s self-expression and I was able to get physically closer, which created a more personal feel to the music-making and enabled a relationship to develop.
The flute as an extension of the voice
The flute can be thought about and used as an extension of the therapist and his or her voice. First, it is possible quickly to take away the flute in the middle of a melody and sing the rest with your voice in a seamless way, providing a continuous melodic line whilst also simultaneously enabling your client to become actively engaged. The following case example used this technique.
Case vignette: Simon
One-year-old Simon was seen for music therapy in a hospital ward and was recovering from an operation to counteract the damage to his lungs from continuous vomiting. He watched transfixed as I put my flute to my mouth and started to play a few notes mid-register. I stopped and then played a few more notes moving up and down scales in a melodic way, watching Simon intensely for signs of response. At first he seemed startled, but then his face softened and he began to move his body to and fro from his steady base in his Bumble chair. He looked up and smiled and I then sang the next phrase. After this, I blew the flute and sang again to Simon’s movements. He increased his movement and engagement with me in this joint activity and when I next blew and then waited, Simon made his own vocal sound in the space. A series of flute and vocal exchanges then took place to both his and his mother’s delight.
In this case, the waiting was as important as the notes. Also, I paid extra attention to Simon’s tempo and timing, wondering whether I had perhaps played too quickly before. Simon almost fooled the doctors by his incredibly sunny disposition, despite vomiting and being in hospital. By looking at his X-rays the doctors discovered that his lungs were badly affected. In a similar way, by slowing down the musical interaction I began to notice Simon’s breathing and aimed for more control and ease for him, by paying attention to his internal movement as well as his external movements.
A second function of the flute acting as an extension of the voice is that it can accompany a vocal line when the client is singing. The combination of the flute and the voice creates an opportunity for a shared experience with the therapist. If the therapist joins in through singing, this will often mean the client drops out and stops singing. By accompanying with the flute we can do the same thing, but we are also different and separate.
The instrument that reached where others could not
Esther Mitchell
At the age of nine, I discovered a small black and silver box in the dining room. It looked remarkably like something I had seen at the doctor’s. Was someone ill? Guiltily, unseen, I opened the lid. Within, however, was not the stethoscope I expected but, in three enticing pieces, my first flute.
Although I studied technique and tone for 14 years through the joy of lessons and chamber music and the struggles of exams and performances, it was not until I came to train as a music therapist that I really connected with my flute. It was through improvisation that it really became a part of me, an extension of my voice through which I could express my emotional state and also increasingly, reflect back that of another.
I have used my flute within clinical work with a wide variety of client groups and have often wondered why it can apparently entice individuals into interaction where other instruments have seemed to fail. My conclusion is that this is due to its similarity with the human voice. My voice is naturally low, and the flute provides me with the higher pitches I lack. With it I can meet a range of vocal sounds produced by those I work with, which test my voice beyond its limits.
I work for Thomas’s Fund, a registered charity that provides music therapy in the home for children and young people with life-limiting conditions and/or disabilities, who, owing to their medical condition, are too unwell to attend school for prolonged periods. Our work is short-term, with clients being offered on average 14 sessions, including assessment. Those referred, from babies up to the age of 19, vary greatly in their physical and mental state. Some clients live a few minutes’ walk away from where I park my car or up several flights of stairs. So our instruments need to be compact, and I have come to respect the choice my parents made – that I should learn the flute, not the harp – as I swing its bag over my shoulder or open the case in the confines of a small cubicle, never ceasing to delight in the wonder on a child’s face as I put the shiny pieces together.
Case vignette: Ben
Ben, aged 20 months, grinned broadly as I began to sing hello to him, softly strumming the guitar. The child, who had been on the move constantly, rolling over and over across the room at our initial meeting, barely aware of me, was sitting attentively on the floor in his living room. His mother sat next to Ben and he was giving me steady eye contact. I inched a little closer and began to sing again. Ben’s face dropped and he began to sob, then to shake with fear. He could not be consoled or distracted whether I sang, played or moved away, leaving instruments near him, which his parents explored with him. After 15 minutes, we ended the session, Ben calming as I packed away and left. Sessions two and three continued in a similar manner with his parents becoming understandably uncertain about music therapy in general. I decided therefore to work without instruments; I would use my voice and props such as puppets and scarves and I hoped would slowly gain his confidence.
Ben has Rubenstein Taybi syndrome, a chromosomal disorder that affects his mental development, his sight and hearing, his digestion, his joints and his growth. Much of Ben’s first traumatic year of life was spent in hospital, and it was hoped that music therapy could support him in the development of his very delayed communication, social and physical skills. Ben made virtually no vocal sounds and gave very little eye contact.
Ben